Classical public health thinking in São Paulo during the era of health centers and health education

The article reviews the ideas and concepts of health service organization that followed the introduction of the Health Center model by the Health Service reform in 1925. It discusses the thinking of Geraldo de Paula Souza, Rodolfo Mascarenhas and Reinaldo Ramos, distinguished representatives of “classical thought” of public health in São Paulo, Southeastern Brazil. DESCRIPTORS: Public Health, history. Health Care Reform. Social Medicine. Primary Health Care.

Public Health Service (Serviço Especial de Saúde Pública, SESP) and intellectual authority defi ne general characteristics that may be termed, in Brazil, as the "classical thought" in public health (within the scope of the era of health centers and public health education).c I do not claim that this is the only possible trajectory, not even the most representative.Briefl y browsing studies that follow this historical interface for the area of the Federal District in Brazil, for example, is enough to show that events in that geographical area do not follow the São Paulo school of thought. 3,38

GERALDO DE PAULA SOUZA AND FRANCISCO BORGES VIEIRA
The names of Paula Souza and Borges Vieira are closely associated with the Public Health Reform of São Paulo in 1925 and the foundation of the São Paulo Hygiene Institute, landmarks of the Brazilian public health rupture from the French tradition.At different depths of analysis, the studies by Rodolfo Mascarenhas, [12][13][14][15][16][17][18][19][20][21] Nelly Candeias, 5 Maria Alice Ribeiro, 36 Lina Faria [7][8][9] and Cristina Campos 2 are mandatory references for that period.
After completing the then-recently-created Doctorate in Hygiene and Public Health in the John Hopkins University, Paula Souza and Borges Vieira returned to Brazil to become Director and Vice-Director of the Hygiene Institute in 1922.At the same time, Paula Souza was nominated for the General Board of Directors of the Public Health Service of the state of São Paulo, and the two boards of directors were closely associated for the next fi ve years.Resistance was not insignificant.As a state senator, Oscar Rodrigues Alves expressed strong objection against their holding both board positions and anticipated confl icts of functions and undue privileges; 9 and Luiz de Toledo Piza Sobrinho, an eminent representative of another political clan, complained that the Institute was subordinated to the Internal Affairs Department and not to the Public Health Department. 5 Although it borrowed many contents from the reform promoted by Arthur Neiva in 1917, the Decree nº 3,876, of July 11, 1925, d also known as "Paula Souza reform", may be classifi ed as a landmark in the institutional break with French infl uence in Brazilian public health, as the public health code of São Paulo up to that date was an adaptation of its French congener.e A new era of service organization began, in which Health Centers (HC), inspired by the American tradition, should be seen as the "axis of public health organization", an expression that would last for the whole century. 42However, HCs were only the most effi cient administrative means to achieve public health education, the true basis of the reform: "the development of a public health awareness in populations." 39new public health lexicon was instituted, commanding new references and indoctrinators.Districts, coordination, integration and other administrative principles were rapidly adopted.The recommendation of a "full time regimen", however, was not.In general, the organization of the HC was guided by adopting the family as the unit of care, mother and infant follow-up, vaccination, annual routine checkups, home visits, public health surveillance and communicable disease prophylaxis.There is no need to extend the discussion about the break resulting from the new principles and concepts described years later by the reformists themselves and extensively contextualized in a specifi c review. 23,42However, some additional characteristics resulting from that new discursive matrix should be pointed out.
The American infl uence in São Paulo healthcare, that is, the preponderance of the Rockefeller Foundation over the School of Medicine, which was parallel with hygiene, emphasized, as expected, the liberal ideas in that fi eld.Its translation responded by the special "dualism" revealed in the separation of preventive from curative medicine, the latter in the hands of the private sector.Defended convincingly by Paula Souza, a solid culture of exclusive public health education and preventive medicine was established in São Paulo public health, removing any medical care not having an epidemiological character from the HC. 43Such infl exibility, however, was not found in the American discourse, also in its initial stage at that time. 32,45Souza and Vieira were not likely to be unaware of the liberal wrath aroused by the idea of incorporating free medical care into the American HC in that second decade when they studied abroad; 45 nor of the resistance to any attempt at the socialization of Medicine. 6However, supported by the fi rm belief in their scientifi c effectiveness, they were convinced that the provision of curative care in the HC would be totally counterproductive to popular health education. 42e desire to have a public health policy guided by science was not new, at least not rhetorically, and may be confi rmed by the Decree that regulated the Public Health Service in 1896, which started by defi ning "the scientifi c study of all issues associated with public c Here assume that classical thinking in Brazilian public health also includes a previous phase of French infl uence, inserted in the epistemological references of bacteriology and urban sanitation.Oswaldo Cruz, Carlos Chagas, Emílio Ribas, Belisario Penna and Arthur Neiva are the outstanding names of this phase.d 13, p. 49.health."f Moreover, sanitation of cities under the direction of Emílio Ribas and Oswaldo Cruz, to mention only the two greatest iconic fi gures, enormously raised the status of science in the bacteriological era that preceded the implementation of HCs.However, the semantics engineered at the Johns Hopkins incisively changed the structure of the public health discourse, which after that was uttered exclusively from a scientifi c enunciation position, peremptorily separating itself from any political intentionality in their recommendations, but, in turn, reverting this order in relation to any discordant ideas.g Therefore, Paula Souza saw himself as a man of science and, as so, was seen as distant from political intentionality and lesser unscientifi c objectives.h Supported by a wide political, familiar (and international) context, he assumes a political position, but refuses to treat it as such: "in the United States, the choice of Universities rather than Departments of Health is justifi ed not by the greater level of culture in those institutions, but by their greater distance from political party interests" (quoted by Candeias, 1984). 5A framework of this vision was molded here, based on the example of his father, Francisco de Paula Souza, who passed over an infl uential political career to found and direct the Polytechnic School, always in the defense of a rational thinking. 26 fact, however, this scientific/rational obstinate position by Paula Souza predicted a phenomenon of technological transition that included the highly praised American HC standard: their administrative effi ciency.The bases of the bureaucratic administrative model in public health were laid at that time: technical and hierarchical, in opposition to the inherited charismatic administration.It was also the motive for the emphasis on the imperative defense of the public health specialization that quixotically crossed decades (remember that the specialization courses were already part of Neiva's ideas).
Another point diligently defended, although not achieved in the reform itself, was the subordination of Hygiene School to the Public Health Service; 41 this vision was reinforced by the "success" of training primary school teachers as home visitors, motivated by the lack of nurses. 42p.41 Having left the Public Health Service in 1927, Paula Souza remained on the board of the Hygiene Institute until his death in 1951 and held prestigious international positions in connection with the Rockefeller Foundation.When in one of these positions, he was in charge of submitting, together with the Chinese representatives, a motion to create the World Health Organization. 46Along his stay in São Paulo, Paula Souza dedicated his efforts to studying and publicizing the principles of labor hygiene and nutrition, which led him to participate in the creation of the Institute for the Rational Organization of Labor (IDORT, from the Portuguese Instituto de Organização Racional do Trabalho) and the organization of the Food Service of the Industry Social Work Organization (SESI, from the Portuguese Serviço Social da Indústria). 47In his career and publications as a whole, in which opinion essays predominate, his notably political participation in public health stands out over an undeniable diplomatic nature that only the most refi ned aristocratic education could provide.With Borges Vieira, who died in 1950, he formed a global and indissociable partnership, although he alone undoubtedly had the essential task of moving things along.

RODOLFO DOS SANTOS MASCARENHAS
Rodolfo Mascarenhas was one of the brightest intellectuals in Brazilian public health and one more to succumb to the fate of our poor collective memory.A physician graduated in 1932 in Rio de Janeiro, he started his private career as a clinician and pulmonologist in São José dos Campos, a career that was soon interrupted as he was assigned the municipal government in that town.He gave up both positions to follow a career in public health.For that purpose, he specialized in the Hygiene Institute in 1937 and felt the need to deepen his social and political understanding, which led him to another degree from the Free School of Sociology and Politics in 1940.His extensive production remains the main source of the São Paulo public health thinking in the fi rst half of the 20 th century and is the basis of all the studies at that time, although credits were not always given.Reinaldo Ramos defi ned his presence as follows: 37 f São Paulo (Estado).Decreto 394 de 7 de outubro de 1896.Approva o regulamento do Serviço Sanitario.[citado 2011 jun 28].Available from: http://www.al.sp.gov.br/repositorio/legislacao/decreto/1896/decreto%20n.394,%20de%2007.10.1896.htmg This characteristic is clearly seen in the extensive review by Lina Faria. 9h This is a spice found in large pinches in the São Paulo literature of a historical nature.p.82 "We can claim without fear of being imprecise that nothing important took place in public health in São Paulo in the last thirty years without Mascarenhas' participation and presence, at times personally in the site of events, at other times backstage through his words of incentive and wise advice, and still other times indirectly, by means of the innumerable technicians that he taught and advised." Differently from the 1925 transition, in which Paula Souza and Borges Vieira fought for poorly-conceived neighborhood HCs in the capital city, during Mascarenha's time these principles had already become part of the common sense discourse.Under the guidance of João de Barros Barreto, a former Johns Hopkins fellow student, the Vargas era created a solid bureaucratic structure in public health in Brazil, strongly oriented to the HC concept and the bureaucratic administration model. 10,23However, although the revolute context of the break caused by the Pan American public health concepts was already a thing of the past, now the planet was troubled by the capitalist-communism divide.That tension added a certain anguished tone to the conclusion of the Mascarenhas's thesis and the assumption of "Three ways…" for the organization of public health.i Therefore, the overall debate was clearly one of the major national issues, at a time when the expression of the Vargas ideology was found everywhere, even in Borges Vieira. 49e major issue was a byproduct of the core differences in Brazilian liberalism about the ideal of decentralization.The "deconcentration" formula was established by Oliveira Viana and rigorously followed by Barros Barreto: administrative decentralization together with political centralization.Similar to the his methodological rigor, Mascarenhas dedicated time to thinking about the rationality of public health administration and, maybe infl uenced by his executive experience, carried it on in a proper and unusual way for the traditions of the time, using broad economic bases.3][14] However, behind his appreciation of deconcentration, Mascarenhas corroborated a predominant fear of a municipal policy fragility.Not by chance, his aversion to favors, nepotism and corruption in public health politics was clear in his use of the expression "politicalha", which in Portuguese means "bastard politics" approximately, the same word used repeated times by Oliveira Viana. 48 this domain, his discourse was antinomic to that exported by the Rockefeller Foundation in the 1920s, as it clearly took into account the precedence of political over technical decisions; 15 probably infl uenced by his own political experience and his education in sociology, but certainly also because the national strengthening of political parties and the creation of the Ministry of Health defi nitely took the debate about public health to the arena of political party discussions. 11e 1950s saw Mascarenha's academic maturity, when he did not refrain from reaffi rming his complicity with his mentors' ideas."As already said by the late public health professors Geraldo de Paula Souza and Francisco Borges Vieira, the 'health center is the axis of the public health organization'". 15However, as seen before, many years have gone by, and, as it is diffi cult to perceive one child's growth, it was also not very apparent that the public health discourse was structured upon another reality and complexity, often contradictory to the original precepts.Hygiene remained silent in the bottom of the shelves to make room to preventive medicine, and "dualism" was a hollow phrase in discourse: "there are no longer clear limits between preventive medicine […] and curative medicine". 15And, although he did not shy from forcefully defending a career and specialization in public health, the focus had shifted to medical teaching after the adoption of the transverse curriculum of preventive medicine. 19In this interim, however, the worthy position held by the Rockefeller Foundation before never went cold, as it was rapidly replaced with the Kellogg's Foundation.
Interested in medical teaching in public health, Mascarenhas closely followed and publicized knowledge about integral primary health care. 19He focused, as none before, on the conceptual defi nitions involved without, obviously, escaping the expression of the normative DNA of all Brazilian public health workers. 16,17He devoted special attention to the integration concept, 18 and, in the 1970s, his semantics were not very different from the one that reaches the Brazilian Unifi ed Health System (SUS) under the integrality aegis, except for the idea of "systemic", absent from classical thinking.
"Medicine and Public Health should be applied globally, integrally, without rigid divisions between preventive and curative activities.Individuals, sick or healthy, should not be observed out of their physical, biological and social environments.Public health problems should be studied integrally in contact with problems that are not of a public health nature [...].The right to health care, extensive to all citizens, is defi ned." 20,p.2-3However, even the illustrious are subject to the passing of time, and his fi nal text about primary health care, as i "The fi rst […] to follow the current progression of the public health services […] The second […] a complete, full reorganization of all the activities of the aforementioned Department of the state […] The third road is dimly lit.It cannot be seen.It is completely unknown.[...] This part, interested in social and economic improvement not achieved, may lead to a legal or illegal movement that will completely change the political and economic structure of the country.p.533-7 well as the other chapters in the same collection, make evident the distance from those that were part of the vibrant discourse of primary health care set in motion by the Alma-Ata Declaration. 21

REINALDO RAMOS
Reinaldo Ramos is one of the last bulwarks of the classical line of public health in São Paulo, the restatement of an era of careful thinkers involved in Pan American health principles, who, however, did not miss the identity of a national line of thinking. 37Since the mid 1950s, Brazilian public health had been following three major paths in healthcare.On one side, the role of social welfare in healthcare was strengthened and was marked by the budgetary inversion of positions. 28On the other side, an era of public health optimism had led Mário Pinotti, the head of the Health Ministry during the Kubitschek government, to concentrate ministerial policies on eradication campaigns, while the states were in charge of the development of local primary healthcare networks by means of associations with SESP). 27Ramos' ideas developed in the context of the technical objectivity and political autonomy of this service and the planning of the public health organization based on local networks.
His doctorate thesis "Indicators of health levels: their application in the city of São Paulo (1894-1959)" had great technical infl uence on the administrative approach to public health in São Paulo. 30However, in the context described here, our specifi c interest is in the 1972 study "Public health integration", an admirable habilitation thesis that would hardly be surpassed in its objectives of revising the national and international history of this issue.In the dedication, as usual among those associated with SESP, Ramos expressed his admiration for the efforts made in the name of public health and national development: 32 "[…] it is in honor of a group of colleagues, several already dead, who faced countless hurdles and pledged the best years of their lives to the implementation of the most perfect healthcare organization that this country has ever known." The infl uence of Rodolfo Mascarenhas is easily identifi ed in the structure of his fi rst writings.Typically, his article "Considerations about the problem of medical and public health care in rural areas" begins by stating the problem of defi ning rural areas, follows the descriptive diagnosis of public health issues, makes "some suggestions for the problem" and concludes in the form of topics. 29In that text, he discusses the diffi culty of professional retention, a question that, in general, remains relevant fi ve decades later: "Numerous SESP physician remain in this organization only for as long as they can save money to venture into a clinic in larger towns."The medical problem was not alone, because "closely associated and not less important […] is the problem of nurses."Reality forced by practices is what made SESP take up healthcare as a basic activity in 1948, 4,32 eliminating from its discourse the old initial idealism of exclusive public health education: "As these are the most expensive and differentiated professionals in the team, and in face of their poor distribution in our country, the organization of healthcare should prioritize their use in what only they, because of their qualifi cation, can do.Therefore, it is not enough to accept healthcare as a basic public health activity [...] but also to acknowledge that this activity is the raison d'être of retaining a physician in a public health unit. 29milarly to other classical public health physicians, Reinaldo Ramos responded to the polemic raised by the Mário Magalhães motto: "There is no doubt about the fact that health problems, at least those of a primary nature and the ones that concern us, are superstructure problems."However, he ponders that "there are profound causes that escape the action of the healthcare agencies," and that disease and early death should not be separated from impoverishment, which may reduce the infl uence of the public health programs on the levels of health of the rural populations. 29llowing the emphasis that Pan American Health Organization assigned to the 1960s, Ramos had a special interest in planning, a bustling fi eld under the infl uence of Gunnar Myrdal and Celso Furtado.He was convinced of its association with development: "We understand planning, in its broader meaning, that is, economic and social planning, as the means to reach the full development of a national community." 31Based on this broad vision, two fi elds of planning emerged for public health, one for "intrasectorial integration" and the other for "intersectorial integration".
The fi rst, the basis for his 1972 thesis, dealt with integration and coordination of healthcare services and would gain a more clear meaning in the concept of "system" a few years later.The second case, weakened in face of the recent discourse of "public health reform", recommended that the healthcare sector should be an essential technological sector for the economic and social development, so that the "associations between health and development should be identifi ed as precisely as possible." 31p.5All this disciplinary accumulation of the classical line of thinking translated into specialization courses for public health specialists and service workers, distant from "merely academic or speculative aims." 31 Long and comprehensive at fi rst, with a total of 480 hours and beginning with a fi ve-week introductory course, 34 courses would be forced to adapt to mass education for the public health career, at last described in the Leser Reform. 44A culture of evaluation -and self-evaluation -was seeking a place in the sun. 33At that time, the old managerial aspirations of the Hygiene Institute had long been dissipated, and the School of Public Health was focused on education, research and consulting.This was the context of intensive participation in the Department of Health reform in 1968, during the fi rst term of the Walter Leser administration. 24

Final considerations
In this brief depiction of three generations of the Hygiene Institute of FSP/USP I aimed at outlining a picture with some of the main discourse matrices that formed the classical thinking of public health in São Paulo that followed the paradigm break represented by the ideals of health centers in the 1920s.Specifi c readings are certainly necessary for the political and epistemological understanding of this body of ideas and concepts locally limited at fi rst, but that expanded at the speed of sectorial and social development into complex structures and reached the 1970s as strategic elements of regional and national development.Our three characters are easily identifi ed in our purpose of identifying matrices of public health thinking, exactly by the academic success that they attained.However, our intention is that they represent all the brilliance of those that, although they dedicated fewer efforts to recording, chose to deal directly with the mess resulting from building a nation.
Five years later he completed his Doctorate at Yale University and, after an invitation from Paula Souza, returned to Brazil to become a Public Health Technique professor in the School of Hygiene and Public Health of Universidade de São Paulo.He defended a habilitation thesis in 1949 and was Dean of that School from 1966 to 1972.